11.
5 
Sacrococcygeal joint:
Coccyx anterior 
Patient sidelying
Assume somatic dysfunction (S-T-A-R-T) is identified and you wish to mobilize or thrust
the coccyx posteriorly.
Key
❊ Stabilization
● Applicator
➡ Plane of mobilization or thrust
(operator)
➩ Direction of body movement
(patient)
Note: The dimensions for the arrows
are not a pictorial representation of
the amplitude or force of the
mobilization or thrust.
The operator must exercise care and
attention to ensure that the patient is fully
informed as to the nature of this procedure.
This technique involves both assessment
and treatment via a rectal approach. It is
assumed that the operator will examine the
anal and rectal region to determine whether
there are any contraindications to
performing this procedure. This technique
can be used either as a means of gently
mobilizing the sacrococcygeal joint or
applying a high-velocity low-amplitude
(HVLA) thrust to the coccyx. Coccydynia
can be severe, and the choice of technique
depends as much upon patient comfort as
perceived efficacy of approach. Practitioners
should become familiar with mobilizing the
sacrococcygeal joint before attempting a
thrust to the coccyx.
1. Contact points
a. Anterior aspect of the coccyx through the
posterior wall of the rectum.
b. Posterior aspect of the coccyx.
2. Applicators
a. Lubricated index finger of operator’s
gloved right hand.
b. Thumb of operator’s gloved right hand.
3. Patient positioning
Lying in the left lateral position with the
maximal amount of flexion of the hips,
knees and spine consistent with patient
comfort. The patient should be fully
undressed so that access to the anal canal is
possible. The buttocks should be at the edge
of the couch.
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B HVLA thrust techniques

A B C

Figure 11.15  Sacrococcygeal joint. A: The index finger is placed against the anal margin.
B: The finger is inserted as shown. C: After examination of the rectum, the coccyx is held
between the index finger internally and the thumb externally.

4. Operator stance
  The palpating right index finger identifies
Stand behind the patient, approximately at the sacrum and coccyx through the posterior
the level of the patient’s hip joints, facing wall of the rectum. Place the distal phalanx
the couch and patient’s back. of the right index finger against the anterior
surface of the coccyx immediately below
5. Palpation of contact points
 
the sacrococcygeal joint. Use the thumb of
your right hand externally to identify the
The operator should be wearing a pair of
posterior aspect of the coccyx between the
suitable gloves with lubricant smeared over
buttocks. The coccyx is now gently held
the right index finger. The patient must be
between your index finger internally and
informed that a finger within the rectum
the thumb externally (Fig. 11.15C). Gentle
will cause a sensation similar to that of
pressure is applied in a number of
opening the bowels. Ask the patient to relax,
directions to determine undue tenderness or
and place the index finger of your right
any reproduction of the patient’s familiar
hand against the anal margin (Fig. 11.15A).
symptoms. The mobility and position of the
With steady pressure, insert your right index
coccyx relative to the sacrum is also noted.
finger into the patient’s anal canal in a
cephalic and slightly anterior direction
6. Fixation of contact points
(Fig. 11.15B). The finger will pass through
 

the anal sphincter and into the rectum. If
the patient has difficulty relaxing, ask him /
her to bear down as if opening the bowels
and gently slip your finger past the anal
sphincter and into the rectum. Once
through the anal sphincter, the direction of
the rectum is cephalic and posteriorly along
the curve of the coccyx and sacrum.
Keep your right index finger on the anterior
aspect of the coccyx while applying pressure
against the posterior aspect of the coccyx
with your right thumb. The fixation is gentle
but firm with less pressure against the
anterior surface of the coccyx.

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7. Adjustments to achieve appropriate
 
prethrust tension
The operator should be in a position to
move the coccyx through a range of motion
and in different planes. Ensure your patient
remains relaxed. Maintaining all holds,
make any necessary changes in flexion,
extension, sidebending and rotation of the
coccyx until you sense a state of appropriate
tension and leverage at the sacrococcygeal
joint.
8. Immediately prethrust
 
Relax and adjust your balance as necessary.
Ensure that your contacts are firm. An
Sacrococcygeal joint: Coccyx anterior 11.5
Figure 11.16 
effective HVLA thrust technique is best
achieved if the operator and patient are
relaxed and not holding themselves rigid.
This is a common impediment to achieving
effective cavitation.
9. Delivering the thrust
Apply an HVLA thrust towards you in a
curved plane (Fig. 11.16).
The thrust, although very rapid, must
never be excessively forcible. The aim
should be to use the absolute minimum
force necessary.
299
B HVLA thrust techniques

Summary

Sacrococcygeal joint: Coccyx anterior

Patient sidelying
Mobilization or thrust posteriorly

• Contact points:
• Anterior aspect of the coccyx
• Posterior aspect of the coccyx
• Applicators:
• Lubricated index finger of operator’s gloved right hand
• Thumb of operator’s gloved right hand
• Patient positioning: Left lateral position with flexion of the hips, knees and
spine
• Operator stance: Behind the patient
• Palpation of contact points: Place the index finger of right hand against the
anal margin (Fig. 11.15A). Insert your right index finger into the anal canal
in a cephalic and anterior direction (Fig. 11.15B). The palpating index finger
identifies the sacrum and coccyx through the posterior wall of the rectum.
Place the distal phalanx of the right index finger against the anterior surface
of the coccyx. Identify the posterior aspect of the coccyx between the
buttocks. The coccyx is now gently held between your right index finger
internally and the thumb externally (Fig. 11.15C)
• Fixation of contact points: Keep right index finger on the anterior aspect of
the coccyx while applying pressure against the posterior aspect of the coccyx
with your right thumb
• Adjustments to achieve appropriate prethrust tension
• Immediately prethrust: Relax and adjust your balance
• Delivering the thrust: The direction of thrust is towards you in a curved plane
(Fig. 11.16)

300